Name of Firm____________________________________________________________________
Address (Street/Road)______________________________________________________________
City or Town ________________________State __________________Zip
Code_________________
Municipality
_____________________________________County_____________________________

Telephone ( )______________________

4. This is an application for_____________________________________________________ Permit
(Name of permit, certification, approval, jurisdictional determination or
exemption.)

E. Identify below any individual, corporation or other business organization
having ownership or a controlling interest in the applicant. If applicable,
the chain of ownership or control should be traced to the main parent company.

NAME ___________________________________________________________________________
ADDRESS
________________________________________________________________________
NATURE OF CONTROL ____________________________________________________________

F. Principal Security Holders and Voting Power. Identify owner(s) of all
securities in the applicant corporation having more than ten (10) percent
of value.

I certify under penalty of law that I have personally examined and am familiar
with the information submitted. in this document and all attachments and
that, based on my inquiry of those individuals immediately responsible for
obtaining the information, I believe that the information is true, accurate,
and complete. I am aware that there are significant penalties for submitting
false information, including the possibility of fine and imprisonment.

I hereby certify that ____________________________________________________________
Property Owner's Name
is the owner of the property upon which the proposed work is to be done.
This endorsement is certification that the owner grants permission for the
conduct of the proposed activity and authorizes that staff of DEP may conduct
on-site inspections as necessary for the review of this application.

In addition, the aforementioned property owner shall certify:

1. Whether any work is to be done within an easement -

Yes __________ No __________
(Initial)
(Initial)

2. Whether any part of the entire project will be located within property
belonging to the State of New Jersey

3. Whether any part of the entire project will be located within property
belonging to a municipality or county

Yes ______________ No _____________

______________________________________________
______________________________________________
______________________________________________
Type or Print Name and Address of Owner
if different from Item 1 on Page
1

I, the Applicant/Owner_________________________________________________________or
Applicant/Operator when the owner of the facility and the operator of the
facility are distinct parties)______________________or Co-permittee
(when the Co-permittee is a local governmental unit)
___________________________________________authorize to act as my
agent/representative in all matters pertaining to my application the following
person:

Name ___________________________________Phone______________________________
Address ________________________________County_______________________________
City or Town ______________________State ___________________Zip
Code____________
Occupation/Profession__________________________________________________________

Sworn before me
this ______day of
_________ 19__
I agree to serve as agent for the
above
-mentioned applicant
______________________________________
_________________________________________
Notary Public
(Signature of Agent)

I hereby certify that the engineering plans, specifications and engineer's
reports applicable to this project comply with the current rules and regulations
of the State Department of Environmental Protection with the exceptions as
noted.